Medical Peer Reviewer

Job Profile Summary

A vital role of the CMO Administration team, the Medical Peer Reviewer plays a critical role in consulting on medical necessity in the context of utilization management and ensuring adherence to internal Healthfirst and external regulations.

Duties/Responsibilities

The Medical Peer Reviewer will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations. The Medical Peer Reviewer will render determinations in the format and within timeframes to follow Regulatory and Operational policies. The Medical Peer Reviewer will:

• Maintain productivity standards.
• Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses
• Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed
• Complete mandatory Company compliance training and training in new systems and software.
• Enter each day’s hours worked in Workday, on the same day.
• Perform other duties as assigned

Responsibilities may be adjusted based on changing needs of the organization.

Weekday Requirements

The Medical reviewer requires 25 hours a week of coverage. The configuration of the 25 hours may change with the business needs, with a minimum of 3 days a week, 2 days at 8 hours and one day at 9 hours. Maximum of 5 days a week of coverage. The Medical Reviewer will take 8 hours off during the week after being primary coverage for a weekend, usually the following Friday. Each Medical Reviewer will cover one legal holiday /year and will be compensated Holiday pay and straight hours worked. The Medical Reviewer is eligible for Paid Time Off (PTO) and is required to plan and schedule time off with their direct supervisor following the Company policy.

Weekend Requirements

Each Medical Reviewer is required to be primary coverage one weekend a month. Each Medical Reviewer is required to be available as back up, if needed, one weekend a month. Dental Reviewers have a fixed schedule.

Minimum Qualifications

• Licensed M.D. or D.O. or D.M.D. or D.D.S.
• Board Certified in a specialty recognized by the American Board of Medical Specialties

Preferred Qualifications

• Board Certified in Internal Medicine, Family Practice, OBGYN, Emergency Medicine
• Previous, relevant experience in utilization management and clinical practice
• Knowledge of Medicare, Medicaid, and MLTC plans
• Time management, critical thinking, communication, and problem-solving skills
• Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies
• Knowledge of member satisfaction/incident management and regulations
• Knowledge of quality improvement methodologies

Compliance & Regulatory Responsibilities:

Ensures compliance to internal Healthfirst and external regulations. Licensed M.D. or D.O. or D.M.D. or D.D.S. Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades. Annual Inter-Rater Reliability (IRR) Testing. Complies with the Healthfirst Conflict of Interest Policy for Professionals.

Key skills/competency

• Medical Peer Review
• Utilization Management
• Clinical Judgment
• Regulatory Compliance
• Case Review
• Medical Necessity
• Healthcare Regulations
• Physician Review
• Claim Analysis
• Healthcare Administration